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Hey Pain, Sad to See You Go! (A Review of Adjuvant Pain Medications) | Pain Pod · Pharmacy Podcast Network

• 0:05
  Speaker 1: You are listening to the global network of podcasters dedicated
• 0:09
  Speaker 1: to the pharmacy profession. Welcome to the Pharmacy podcast Network.
• 0:22
  Speaker 1: This is the Pain Pod. You want to see pain
• 0:27
  Speaker 1: look at me.
• 0:34
  Speaker 2: Welcome to the Pain Pod, the podcast for all things
• 0:39
  Speaker 2: pain management, hosted by the pain Guy.
• 0:43
  Speaker 1: Doctor Mark grow.
• 0:48
  Speaker 2: We'll be collaborating with numerous pain management experts, talking about
• 0:52
  Speaker 2: substance usage disorders, the latest treatment modalities, and the most
• 0:57
  Speaker 2: important important focusing on the pain of our patients as.
• 1:01
  Speaker 1: Leading providers of pain care.
• 1:05
  Speaker 2: And now here's our host, a man wanted in all
• 1:09
  Speaker 2: fifty states, a suburban city like mountain man without the beard,
• 1:16
  Speaker 2: from the hills of West Virginia and certified in weapons.
• 1:21
  Speaker 1: Of mass destruction.
• 1:22
  Speaker 2: Response Yes, doctor Mark Holby.
• 1:32
  Speaker 3: All right, all right everyone, welcome back to the Pain Pod.
• 1:37
  Speaker 3: We put out the advertisement to the mantra of come one,
• 1:40
  Speaker 3: come all to the Pain Pod, and here you are,
• 1:42
  Speaker 3: so welcome back pain pod Nation.
• 1:45
  Speaker 1: Well here we are with this episode today. Hey pain
• 1:49
  Speaker 1: sad to see you go. Basically we'll be reviewing ed
• 1:53
  Speaker 1: you even pain medications really highlighted by antidepressants, but you
• 1:57
  Speaker 1: know the rest of the gang as well. So tried
• 2:00
  Speaker 1: to come up with saying there of well, typically not
• 2:03
  Speaker 1: sad to see the pain go, but has to do
• 2:06
  Speaker 1: something in the realm of antidepressants. Right, So as we
• 2:10
  Speaker 1: you know, review our adjuvenant pain medications, keep in mind
• 2:15
  Speaker 1: the list be long. It's a laundry list of medications.
• 2:18
  Speaker 1: It's basically the you know, the gang that doesn't fit
• 2:19
  Speaker 1: into the other things, right, the non opioids, the opioids
• 2:22
  Speaker 1: of course, but now we jump into our adjuvants. You know,
• 2:26
  Speaker 1: things like I mentioned the antidepressants, whether it's the TCAs S,
• 2:30
  Speaker 1: n ries A, b SSRI's more to come on that,
• 2:34
  Speaker 1: you know, the the the outliers, bupropion, mertazepine, you know,
• 2:38
  Speaker 1: even jumping classes here to alpha two agnis primarily with chlanidine.
• 2:44
  Speaker 1: Then the infamous quote unquote muscle relaxing is much more
• 2:48
  Speaker 1: to come on that here in a hot second, the benzos,
• 2:50
  Speaker 1: the gap of pentanoids, you know, the rest of the
• 2:53
  Speaker 1: gang when it comes to the seizure medications and even
• 2:56
  Speaker 1: cardio medications like anti rhythmics and will run things out
• 3:00
  Speaker 1: with the NMDA antagonists as well. That's that's a lot
• 3:04
  Speaker 1: of different medications. Hence the laundry list, right, But let's
• 3:08
  Speaker 1: jump into first a rather rapid review of antidepressants, particularly
• 3:12
  Speaker 1: for their utilization and pain management. Now you've heard it
• 3:17
  Speaker 1: here and you've heard it many other places before that.
• 3:19
  Speaker 1: You know, all medications come with their baggage. We as pharmacists,
• 3:23
  Speaker 1: we look at how does it work and how much
• 3:25
  Speaker 1: mechanisms and dosage to lead to safety and efficacy, safety
• 3:29
  Speaker 1: being those interactions in side effects, right, efficacy pretty straightforward?
• 3:34
  Speaker 1: Does it work? Right? When you look at indepressants, you know,
• 3:37
  Speaker 1: the baggage, the risks, we got to you know, take
• 3:39
  Speaker 1: them into account. Right. There was even black box warnings
• 3:43
  Speaker 1: like twenty years ago regarding you know, raised suicide concerns
• 3:50
  Speaker 1: along the way. Okay, particularly with our younger generation, those adolescents,
• 3:56
  Speaker 1: you know, those less than eighteen years of age. So
• 3:58
  Speaker 1: there was a black box put on antidepressants. But you know,
• 4:03
  Speaker 1: did did a black box work or not? Well, there's
• 4:06
  Speaker 1: a lot of opinions out there, but you know there
• 4:09
  Speaker 1: was at least once they that actually showed that well. Unfortunately,
• 4:12
  Speaker 1: those attempts actually increased after the black box warning. You know,
• 4:16
  Speaker 1: cause and effect. Causation is different than correlation. We got
• 4:19
  Speaker 1: to watch with that but you know, one of the
• 4:20
  Speaker 1: bigger picture things when it comes to the baggage overall. Right,
• 4:24
  Speaker 1: So typically when we're talking antidepressants in pain management, we're
• 4:28
  Speaker 1: really concentrating on the nor epinephrine effects as far as
• 4:31
  Speaker 1: witch transmitter. Serotonin certainly comes into play on the psychological
• 4:35
  Speaker 1: side of pain along with dopamine, but nor a benefron's
• 4:39
  Speaker 1: really where it's at. So what really gets highlighted is
• 4:41
  Speaker 1: typically our TCAs, our tricyclic anidepressants, our sn R eyes
• 4:46
  Speaker 1: you know, selective serotonin or epinephrine reuptake inhibitors, and then
• 4:50
  Speaker 1: the good old guys of bupropion and are tacitene along
• 4:53
  Speaker 1: the way as well. So well, let's dive into the
• 4:56
  Speaker 1: TCAs first. So well, why they called tricyclic cool, They
• 4:59
  Speaker 1: got three it's pretty much how they are. Keep that
• 5:03
  Speaker 1: in mind for one of those pesky muscle relaxes later
• 5:06
  Speaker 1: on in the conversation. But you know, they've all got
• 5:08
  Speaker 1: the three rings along the way. You can break TCAs
• 5:12
  Speaker 1: down though, basically into our tertiary and secondary. Okay, so
• 5:18
  Speaker 1: you know the tertiary are going to have an extra
• 5:21
  Speaker 1: methyl group on that nitrogen hanging out on the tail there,
• 5:25
  Speaker 1: the carbon tail on the structures. Okay, that's medkim going
• 5:29
  Speaker 1: from nerdy to conversational. I guess, okay, the difference though,
• 5:33
  Speaker 1: you know that that methyl group it changes things, right
• 5:37
  Speaker 1: Oftentimes when we see a methyl group at it on,
• 5:39
  Speaker 1: we start talking about LiPo felicity and whether it crosses
• 5:41
  Speaker 1: a blood brain burrier or not. And let's translate that
• 5:44
  Speaker 1: for our our you know, patients listening in too. It's basically,
• 5:48
  Speaker 1: you know, does have more of those sedative properties or
• 5:51
  Speaker 1: you know CNS effects overall. Right, So the tertiary TCAs
• 5:56
  Speaker 1: our friends, there is am atripolene docs a PIN, which
• 6:00
  Speaker 1: by the way is just adding an o t amatriplene,
• 6:02
  Speaker 1: then imimpromine and clummempromine, which by the way is just
• 6:05
  Speaker 1: adding a chloride to emimpromine. It's really two base structures
• 6:09
  Speaker 1: before tertiary TCAs. Overall. Then our secondaries are desipermine, which
• 6:15
  Speaker 1: is the metabolite of m impromine, and nor triptlene, which
• 6:18
  Speaker 1: is the metaboloid of amatriplene. We don't tend to see
• 6:22
  Speaker 1: do zippermine utilization all that much and prescribing and dispensing.
• 6:25
  Speaker 1: So you know, if you had to remember it one
• 6:27
  Speaker 1: way you can remember secondary would be the primary one
• 6:29
  Speaker 1: being or you know, the most popular one of the
• 6:32
  Speaker 1: secondary TCAs being nor triptlen. Where does that come into
• 6:36
  Speaker 1: play as far as affecting our patients. For patients and pain,
• 6:41
  Speaker 1: you know, sometimes we want to help with sleep, Well,
• 6:44
  Speaker 1: those tertiary TCAs can help with that, you know a
• 6:47
  Speaker 1: little bit more on the hissminergic and muscarinic side of
• 6:52
  Speaker 1: things as far as mechanisms, whereas are secondary TCAs highlighted
• 6:57
  Speaker 1: by nor triplen have less of that. So if there's
• 7:00
  Speaker 1: concerns for side effects of tiredness with TCAs for a
• 7:03
  Speaker 1: patient in pain, well nor triplane might be a preferred
• 7:06
  Speaker 1: answer compared to the tertiary TCAs Along the way, So
• 7:11
  Speaker 1: a couple of pearls when it comes to TCAs within
• 7:14
  Speaker 1: pain management compared to say major depressive disorder, there's usually
• 7:19
  Speaker 1: a faster onset of efficacy and there's usually roughly about
• 7:23
  Speaker 1: half a dose that's needed compared to depression treatment. Along
• 7:26
  Speaker 1: the way, Gotta watch when we combine pain management treatments though,
• 7:32
  Speaker 1: say you have an opioid with the TCA, there's going
• 7:34
  Speaker 1: to be additive anti cool energic side effects, and there's
• 7:37
  Speaker 1: even that potential based on protein binding for increased opioid
• 7:42
  Speaker 1: serum levels, so we got to watch for that along
• 7:45
  Speaker 1: the way. Yes, even a simple TCA with a simple
• 7:48
  Speaker 1: prescription opioid can be a concern. Right now, on the
• 7:53
  Speaker 1: scale of how do these things work, we're usually looking
• 7:56
  Speaker 1: at the comparison for serotonergic effects compared to nourope effron effects, right,
• 8:02
  Speaker 1: So nord triplene kind of wins the show as far
• 8:04
  Speaker 1: as the antidepressant that has more relative norripenefrin effects compared
• 8:10
  Speaker 1: to Obviously SSRIs would be completely tipping the scale over
• 8:15
  Speaker 1: to serotonergic effects. But right in the middle of the
• 8:18
  Speaker 1: gang would generally speaking anyway, would be things like douloxetine
• 8:22
  Speaker 1: or even amatriplene along the way. So there we're talking
• 8:25
  Speaker 1: like SNRI compared to TCA, right, So that's a natural
• 8:30
  Speaker 1: transition here to our SNRIs. There's really not that many folks.
• 8:33
  Speaker 1: It gets complicated quick for some reason. But you know,
• 8:37
  Speaker 1: at a core we have duloxetine, venlafaxine, and mil nasa prane. Okay,
• 8:42
  Speaker 1: Deloxetine is also available in er formulation venlaffexine is also
• 8:46
  Speaker 1: available in a des venlaffexine isomer formulation along with a
• 8:52
  Speaker 1: desvenlaffexin er formulation. Mil nasa prane is also available as
• 8:57
  Speaker 1: its active isomer of levo mil acipran. But when it
• 9:01
  Speaker 1: all comes down to it, the three cores are duloxetine, venlafaccine,
• 9:06
  Speaker 1: and mil massapran. Now, as far as things to know,
• 9:09
  Speaker 1: for duloxatin, it comes up in a lot of different guidelines.
• 9:12
  Speaker 1: You know, its first FDA approval was all the way
• 9:14
  Speaker 1: back in two thousand and four for major depression and
• 9:17
  Speaker 1: diabetic neuropathy, but that's almost ancient history at this point.
• 9:21
  Speaker 1: Since then, it's also been approved for you know, general
• 9:24
  Speaker 1: anxiety disorder, fibromyalgia, and even chronic musculus skeletal pain. Hence
• 9:29
  Speaker 1: we see it within guidelines and utilization overall. Now, for venlafaccine,
• 9:36
  Speaker 1: some might say vitamin V. You know, it's got different stereoisomers,
• 9:41
  Speaker 1: hence the different products that are out there. As far
• 9:44
  Speaker 1: as FDA approvals, the first was back in the nineties
• 9:47
  Speaker 1: for major depressive disorder. Now a little little pearl when
• 9:50
  Speaker 1: it comes to venlafaccine is where it hits home folks,
• 9:54
  Speaker 1: So one hundred and fifty miligrams per day or less
• 9:57
  Speaker 1: you typically get action of an SSR. If it's more
• 10:02
  Speaker 1: than one hundred and fifty milligrams per day, you get
• 10:05
  Speaker 1: some s n R I effects, hence the class. When
• 10:09
  Speaker 1: the crank the dose higher than three hundred milligrams per day,
• 10:12
  Speaker 1: which you got to watch with, you started also getting
• 10:14
  Speaker 1: dopaminergic effects as well too, all right. Next up was
• 10:18
  Speaker 1: mil nasa pran as far as the three core snries
• 10:23
  Speaker 1: along the way, so that was approved back in two
• 10:25
  Speaker 1: thousand and nine for fibromyalgia. So it's you know, been
• 10:28
  Speaker 1: a while since we've had multiple new novel medications, like
• 10:33
  Speaker 1: actual different substances for fibromilsia. We've had some recent formulation changes,
• 10:39
  Speaker 1: but you know, not too much in that accord overall.
• 10:43
  Speaker 1: Along the way. One of the main things with the
• 10:45
  Speaker 1: mil nasa pran is that there's no SIP for fifty interactions,
• 10:47
  Speaker 1: so that comes in handy sometimes. But there is an
• 10:50
  Speaker 1: interaction with chlanidine because you know that that would be
• 10:54
  Speaker 1: something of concern overall as well too. All right. Now,
• 10:58
  Speaker 1: as far as the atypic antipressants, I mentioned two of
• 11:01
  Speaker 1: them earlier, so well, mertazepine is the first guy, so
• 11:06
  Speaker 1: since he's got neuroadrenergic and specific serotonergic mechanisms called that
• 11:14
  Speaker 1: NASA NA so nero adrenergic SS specific serotonin energic and
• 11:20
  Speaker 1: A for antidepressants NASA if you want to. It's actually
• 11:24
  Speaker 1: a tetracyclic antipressant. It has one more ring than TCA's.
• 11:29
  Speaker 1: It's also a histaminergic blocker as well, too, proved back
• 11:32
  Speaker 1: in the nineties of course for depressive disorder, but now
• 11:34
  Speaker 1: would be off label within pain. The other atypical andepressant
• 11:38
  Speaker 1: that we talk about in pain management is bupropion. We
• 11:41
  Speaker 1: also talk about that in smoking cessation. You get the
• 11:44
  Speaker 1: classic bogo buy one, get one treatment overall for a
• 11:48
  Speaker 1: patient endeavoring into smoking cessation that also has pain. But
• 11:51
  Speaker 1: we have to mention that to our patients, right, But
• 11:55
  Speaker 1: bupropion is a dopamine and europinephron reuptake inhibitor and a
• 11:59
  Speaker 1: nicke atene receptor antagonists along the way. It's actually got
• 12:02
  Speaker 1: a cathinone chemical structure. So some of our bath salts
• 12:06
  Speaker 1: who knew, right or even amphetamine along the way kind
• 12:09
  Speaker 1: of sort of without that key tone on it. All right,
• 12:12
  Speaker 1: So that's the anydepressants folks. But again remember they do
• 12:15
  Speaker 1: come with their baggage as well. Many would say actually
• 12:19
  Speaker 1: that you know, when we talk about opioids and gradual tapering,
• 12:23
  Speaker 1: you know, the end can be actually in sight, right,
• 12:27
  Speaker 1: But when trying to gradually taper an antidepressant, because of
• 12:30
  Speaker 1: the change in the number of receptors overall, that might
• 12:36
  Speaker 1: be impossible even to completely no longer utilize. So it's
• 12:42
  Speaker 1: you know, even trickier than a gradual opioid tapering. Maybe
• 12:46
  Speaker 1: the same effort with search and antidepressants along the way.
• 12:50
  Speaker 1: Some things to keep in mind as well. All right, Now,
• 12:53
  Speaker 1: within our a juvenant medications, we also have course chlanidine.
• 12:57
  Speaker 1: You know these days I usually mentioned well, you know,
• 13:02
  Speaker 1: klanite is an alpha agonist. It's kind of like a
• 13:04
  Speaker 1: cousin to things like xylazine. You see that in the
• 13:07
  Speaker 1: headlines these days, you know, being laced into or adulterated
• 13:11
  Speaker 1: into heroin products or fentanyl products really these days in
• 13:14
  Speaker 1: the illicit drug supply chain. But it's all about the
• 13:17
  Speaker 1: alpha in that regard. As far as the pearls with clanidine,
• 13:20
  Speaker 1: I'll try and keep it simple and straightforward. There's actually
• 13:23
  Speaker 1: a synergistic effects with when utilized with opioids, the whole
• 13:28
  Speaker 1: protein binding again comes into play. When clanidine is utilized
• 13:32
  Speaker 1: with a TCA there is increased blood pressure and additive
• 13:36
  Speaker 1: sedation as potential concerns as well too. Same thing with
• 13:39
  Speaker 1: cyco benzopren as well. Because well, let's get onward to
• 13:44
  Speaker 1: talking about some structures here for our quote unquote muscle relaxance. Right,
• 13:50
  Speaker 1: let me give you a case. We don't do this
• 13:51
  Speaker 1: often here on the pain Pod, but let me give
• 13:53
  Speaker 1: you a case, right, T pain thirty year old male
• 13:56
  Speaker 1: pharmacist presents this morning to an urgent care clinic with
• 13:59
  Speaker 1: the chief care chief care complaint of extreme lower back
• 14:02
  Speaker 1: pain and stiffness hurts like heck. To paraphrase, mister pain
• 14:07
  Speaker 1: states that is here is back at work while moving
• 14:10
  Speaker 1: a case of soda yesterday morning. He notified management proceeded
• 14:13
  Speaker 1: to work an entire fourteen hour shift, which was really
• 14:15
  Speaker 1: a bad decision on my part, oops, which is the
• 14:19
  Speaker 1: falling also relaxes if any would be most appropriate for
• 14:22
  Speaker 1: my treatment back in the day, Yes, folks, this case
• 14:25
  Speaker 1: is me back in the day, right. Well, a few
• 14:28
  Speaker 1: pharmacists that actually got hurt on the job. Good golly.
• 14:32
  Speaker 1: So anyways, getting back to the case, would you recommend
• 14:35
  Speaker 1: utilization of backlafin curves a prod cycle of benza prene
• 14:39
  Speaker 1: or methacrd mall Well, technically, folks, even though I was
• 14:43
  Speaker 1: prescribed to spend cycle benza prene and he even knew
• 14:46
  Speaker 1: enough to take half a tablet and said the whole thing.
• 14:48
  Speaker 1: I couldn't tell my fiance at the time my name
• 14:50
  Speaker 1: over the phone. So yeah, it had some uh sedative
• 14:54
  Speaker 1: properties to it here, backliffin would be the choice. But
• 14:57
  Speaker 1: why why out of those selections anyway, Well, when you're
• 15:00
  Speaker 1: talking about muscle relaxes, it's really it's like Charles Dickens
• 15:03
  Speaker 1: said in A Tale of Two Cities, it was the
• 15:05
  Speaker 1: best of times, it was the worst of times. We
• 15:08
  Speaker 1: have some efficacy. We got worried about safety along the way,
• 15:10
  Speaker 1: of course, but really it's all about the diagnosis. Is
• 15:14
  Speaker 1: there spasticity or stiffness or are there spasms with the
• 15:19
  Speaker 1: muscle or twitching along the way. So spasms, moving, spasticity, stiffness,
• 15:25
  Speaker 1: that's really the important thing there, right, and we got
• 15:29
  Speaker 1: to keep that in mind in the big picture. So
• 15:31
  Speaker 1: you know, as far as spasticity, I kind of alluded
• 15:33
  Speaker 1: to this with my little case question there myself. But
• 15:38
  Speaker 1: you know, the spasticity medications or muscle relaxes that would
• 15:42
  Speaker 1: attempt to help with stiffness would be tizandine, backloffin and
• 15:47
  Speaker 1: then even gabba pentanoids or benzos or even botulism toxin
• 15:53
  Speaker 1: or even the actual only peripheral acting muscle relax in dantrolene.
• 15:57
  Speaker 1: Whereas spasms are typically preferentially treated with the rest of
• 16:01
  Speaker 1: the gang. There's a pro Dell cycle of benzaprine or
• 16:04
  Speaker 1: fenadrine met the carbon mook lars oxyzome a tax alone.
• 16:07
  Speaker 1: I think that's the whole list. There's a lot of them.
• 16:10
  Speaker 1: I recently heard we want to put xylazine into this
• 16:12
  Speaker 1: list as well too, because we're like, well, where does
• 16:14
  Speaker 1: that fit in? Oh, it's a cousin of quantity, and
• 16:16
  Speaker 1: maybe we should keep it there. Oh, alas we don't
• 16:18
  Speaker 1: really know, Well, we'll make it a muscle relaxing classification.
• 16:21
  Speaker 1: Then it seems to be how we roll for decades. Again,
• 16:25
  Speaker 1: though Dangeline's the actual fun fact, the unactual only perpherally
• 16:29
  Speaker 1: acting muscle relaxant overall. But when we're talking about spasticity,
• 16:35
  Speaker 1: you know, it's really medication or pill formulation wise usually
• 16:41
  Speaker 1: honing into that to zany in and backloffing along the way.
• 16:43
  Speaker 1: But that brings us really to what I call the
• 16:46
  Speaker 1: island of misfit medications. You may remember this island from
• 16:50
  Speaker 1: the Island of Misfit toys from the Rudolph the Red
• 16:53
  Speaker 1: Noise Reindeer Holidays special. These days with streaming, you could
• 16:57
  Speaker 1: watch it anytime of the year. But muscle relaxings, they're
• 17:01
  Speaker 1: basically an island of misfit medications. What do I mean
• 17:04
  Speaker 1: by that, Well, they're like there're something else under a
• 17:07
  Speaker 1: disguise of muscle relaxinges. So those spasticity agents tazanity and
• 17:12
  Speaker 1: it's actually a clanitine analog. Who knew baclafin. It's a
• 17:16
  Speaker 1: gabba analog literally gaba itself, not gabapenttent, but gaba itself.
• 17:20
  Speaker 1: So it's that right, it's a gabapentoid. When you look
• 17:24
  Speaker 1: into those muscle relaxes that are preferential for spasm treatment,
• 17:28
  Speaker 1: kriiza proto, well that's actually banned in Europe, So there's
• 17:31
  Speaker 1: that they took it off the market, is what I mean.
• 17:33
  Speaker 1: But it's it's got an active metabolite that's a barbituit. Well,
• 17:36
  Speaker 1: what's so out there about that? We have barbituits that
• 17:40
  Speaker 1: are prescriptions too, right, they're controlled substances, so be it.
• 17:43
  Speaker 1: But yeah, kruz Aparto is actually the only controlled substance
• 17:46
  Speaker 1: that's a muscle relaxant. Of course you could say that
• 17:49
  Speaker 1: backwards as well too, but yeah, we got to watch
• 17:52
  Speaker 1: with the street perceptions and value of that. Then we
• 17:56
  Speaker 1: have cycle benza. Pren alude to this twice earlier. It's
• 17:59
  Speaker 1: actually a TCA. Yeah, cycle benzoprene is an amatripolean analog.
• 18:03
  Speaker 1: It's a TCA. It has three rings in it, right,
• 18:06
  Speaker 1: or finagerne, Well, that's a diphen hydrogene analog. So it's
• 18:10
  Speaker 1: similar OTC medicines, Well, metha carmel and chlorzoxone. They're actually
• 18:14
  Speaker 1: OTC in Canada. Who knew, right, multiple formulations with other
• 18:19
  Speaker 1: combination medications in there as well too. You've probably if
• 18:23
  Speaker 1: you've listened to other paint Pot episodes, you've heard me,
• 18:25
  Speaker 1: probably heard me pontificate about what's that medication that could
• 18:30
  Speaker 1: potentially turn your patients, you're in purple. Yeah, chlorosoxyzone. It's
• 18:34
  Speaker 1: kind of a fun fact, you know, not common, but
• 18:37
  Speaker 1: definitely something to mention, right that last most relaxing on
• 18:41
  Speaker 1: the island of misfit medicine's a tax alone. One of
• 18:44
  Speaker 1: the things I usually mentioned with that as far as
• 18:46
  Speaker 1: a kind of a pearl. It's just watch for the
• 18:48
  Speaker 1: diuretic metolisone confusion because you know, if you're pulling down
• 18:53
  Speaker 1: the e prescribing, they're oftentimes right next to each other
• 18:56
  Speaker 1: along the way as well too. All right, well, let's
• 19:00
  Speaker 1: see next up back to bigger picture of jubants. We
• 19:02
  Speaker 1: got the benzos, so there we're talking, of course, our
• 19:05
  Speaker 1: zani bars. You gotta watch out with the grape for
• 19:07
  Speaker 1: interactions for three A, four hoh, the whole gang. Right,
• 19:11
  Speaker 1: But you know, they're generally classified into long acting, intermediate acting,
• 19:16
  Speaker 1: and short acting, and many of them have many different
• 19:21
  Speaker 1: FDA approvals along the way, ranging from anxiety, insomnia, muscle
• 19:25
  Speaker 1: spasms like we were talking about, seizures of course, alcohol withdrawal,
• 19:29
  Speaker 1: you name it, you know, just it's very specific to
• 19:33
  Speaker 1: each one along the way. In the AGS Beers criteria,
• 19:36
  Speaker 1: the Beers list for the longest time it was. You know,
• 19:39
  Speaker 1: the recommendation was to avoid the long acting if not
• 19:42
  Speaker 1: in your intermediate acting. But these days, actually the AGS
• 19:45
  Speaker 1: beers criteria for older patients sixty five and older, there's
• 19:48
  Speaker 1: just a recommendation to avoid benzos. But what about when
• 19:51
  Speaker 1: you need them? Hmm. There's different structural classes of benzos.
• 19:56
  Speaker 1: But what really you want to kind of drive home
• 19:59
  Speaker 1: is what makes the ones that are long acting long acting? Well,
• 20:04
  Speaker 1: the answer is pretty straightforward. Kinetically, they have active metabolites,
• 20:08
  Speaker 1: so when our body metabolizes them, they become an active metabolite,
• 20:11
  Speaker 1: which then might become another active metabolid, which might then
• 20:14
  Speaker 1: become another active metabolite that takes a while, so they're
• 20:16
  Speaker 1: longer acting. We got to watch with Bendels. Of course,
• 20:21
  Speaker 1: you know, overuse could lead to respiratory depression with or
• 20:24
  Speaker 1: without opioid. The other side of the coin, though, well,
• 20:27
  Speaker 1: rapid taper could lead to seizures, which could be life threatening.
• 20:29
  Speaker 1: Actual life threatening withdrawal, most would say, unlike opioids, where
• 20:36
  Speaker 1: they're withdrawal respectively, is very unpleasant like any withdrawal, but
• 20:41
  Speaker 1: not necessarily directly life threatening along the way, But still
• 20:45
  Speaker 1: sucks because that's what withdrawal is, right, all right? Next
• 20:49
  Speaker 1: up in our juven to run down gabapentinoids, so obviously gabapentin,
• 20:54
  Speaker 1: but also pregabbling and we probably should throw backliffing in
• 20:58
  Speaker 1: there as well too, right, But you know, gabapenen been
• 21:02
  Speaker 1: around for decades to prove back in nineteen ninety four.
• 21:06
  Speaker 1: I actually recently ran a LinkedIn poll and said, hey,
• 21:08
  Speaker 1: does anybody see gabapat and utilized for seizures these days?
• 21:12
  Speaker 1: And out of a lot of respondents and views, those
• 21:16
  Speaker 1: like two people that said yes. So you know that's
• 21:19
  Speaker 1: where you got to look at the rest of the
• 21:20
  Speaker 1: people in the room or society say yeah, it's hardly
• 21:23
  Speaker 1: ever anymore. Right. Gaba pen is one of my poster
• 21:26
  Speaker 1: kiddos for start logo slow dosing. You never want to
• 21:29
  Speaker 1: lose the opportunity, particularly within pain management, of starting with
• 21:32
  Speaker 1: a too high of a dose leading to side effects,
• 21:35
  Speaker 1: leading to a patient saying I never want to try
• 21:36
  Speaker 1: that again. MAX dose is recognized as thirty six hundred milligrams.
• 21:42
  Speaker 1: Primarily comes into play because if it's biolla availability, being
• 21:46
  Speaker 1: saturated at that point does require renal dosing adjustment, so
• 21:50
  Speaker 1: that comes into play for a lot of folks as
• 21:51
  Speaker 1: well too. When you compare gabapt in to pregabling, like,
• 21:56
  Speaker 1: how do you compare it? So I mentioned gabapentin has
• 21:58
  Speaker 1: saturable nonlinear in other words, kinetics, So the more that
• 22:04
  Speaker 1: someone takes, the less percentage that's by all available. So
• 22:07
  Speaker 1: at you know, thirty six hundred milligrams, it typically plateaus
• 22:10
  Speaker 1: at that point. Pre gableing you do not have that
• 22:13
  Speaker 1: it's ninety percent bioavailability regardless to the dosage. And it's
• 22:17
  Speaker 1: said that the binding affinity of pregable in it is
• 22:19
  Speaker 1: about six times that of gabapentin, and that has been
• 22:23
  Speaker 1: inappropriately yet somehow effectively utilized for comparing dosages of gabapentin
• 22:28
  Speaker 1: to pre gabbling. Basically, just multiply the pregable by six
• 22:32
  Speaker 1: to get what the gabapentin would be, or divide the
• 22:34
  Speaker 1: gaba penen by six and get an approximate pregable and dosage. Again,
• 22:38
  Speaker 1: the pharmacology doesn't really work that way, but it seems
• 22:41
  Speaker 1: to work out in patient care. Last thing I'll mention
• 22:45
  Speaker 1: with gabapentin, one of the notable symptoms of withdrawal from gabapentin,
• 22:50
  Speaker 1: because that's a concern, you know, you want to avoid
• 22:51
  Speaker 1: seizures with withdrawal would be except the olemea. What the
• 22:55
  Speaker 1: heck is that eyeballs protruding from the skull? Go figure
• 22:59
  Speaker 1: that stand out in more times than Halloween. All right,
• 23:03
  Speaker 1: Who do we have left with our adjuvens medications here
• 23:06
  Speaker 1: in pay management? You know? The rest of the gang
• 23:08
  Speaker 1: for the anti epileptic drugs or AEDs, A lot of
• 23:12
  Speaker 1: you know, there's a lot of them, usually say there's
• 23:15
  Speaker 1: a first, second, and third generation based on when they
• 23:18
  Speaker 1: were developed and approved. A lot of times will work
• 23:22
  Speaker 1: on sodium receptors, so that's part of the electricity. They'll
• 23:26
  Speaker 1: usually inhibit gabas inhibitions. It's a double negative of perceived
• 23:30
  Speaker 1: pain and that's where they come into play. But lots
• 23:33
  Speaker 1: of different side effects, especially with those first generation characters, right,
• 23:38
  Speaker 1: Lots of different mechanisms overall, though, plethora of them. Lots
• 23:42
  Speaker 1: of different drug interaction concerns as well too, as far
• 23:45
  Speaker 1: as ZIP for fifty, there's a lot of enzyme inducers
• 23:48
  Speaker 1: and inhibitors and an equal amount with zero for SIP
• 23:52
  Speaker 1: for fifty effects as well too. What about the rest
• 23:55
  Speaker 1: of the gang one or two left here for our
• 23:57
  Speaker 1: juvents the anti arrhythmics. This is I think one of
• 24:00
  Speaker 1: the classic bogos. As I mentioned earlier, buy one, get one,
• 24:05
  Speaker 1: maybe it should be to go treat one, get one,
• 24:08
  Speaker 1: where if somebody has a cardiovascular condition and they're on
• 24:10
  Speaker 1: an anti arrhythmic medication, there's a good chance it might
• 24:14
  Speaker 1: work on sodium channels, so the electricity of the body,
• 24:16
  Speaker 1: which could affect the pain of the body. Right, So
• 24:20
  Speaker 1: if somebody is already utilizing one, then you could have
• 24:23
  Speaker 1: the conversation and say, hey, that may help with your pain,
• 24:25
  Speaker 1: and then that might magically help with their pain, right,
• 24:30
  Speaker 1: because there's a huge psychological side of pain, to say
• 24:33
  Speaker 1: the least. Overall, All right, then we have finally our
• 24:37
  Speaker 1: NMDA antagonists, so n methyl d aspiritit an MDA antagonist,
• 24:43
  Speaker 1: things like methadone obviously that would be with them pain
• 24:46
  Speaker 1: dextromethor fan just the ODC coff medicine. Ketamine that stands
• 24:50
  Speaker 1: out even a mantadine. But really ketamine stands out here
• 24:53
  Speaker 1: as well too. We talked about that in previous episodes
• 24:56
  Speaker 1: in the overall picture of the pain pod. All right,
• 25:00
  Speaker 1: So that was our rapid rundown of the adjuvenant pain
• 25:03
  Speaker 1: management medications. You know, a lot of information when it
• 25:07
  Speaker 1: comes to the enidepressants, the quote unquote muscle relaxes are
• 25:11
  Speaker 1: alpha two chlanidine and any of the cousins thereof the benzos,
• 25:15
  Speaker 1: the gabbas, the seizure medicines, the anti rhythmic medications, and
• 25:19
  Speaker 1: then the NMDA antagonists as well. So that's the whole
• 25:22
  Speaker 1: gang that rounds out the opioids, non opioids and adjuvent
• 25:26
  Speaker 1: therapies for all of our pharmacological options here within pain
• 25:29
  Speaker 1: management there really are a lot of options, and the
• 25:33
  Speaker 1: combinations thereof are exponential, right, So if you combine those
• 25:39
  Speaker 1: three main episodes, really it's probably a couple extras because
• 25:43
  Speaker 1: we dove deeper into enseids and even you know in
• 25:45
  Speaker 1: the seedamnif and so on and so forth. But combine
• 25:48
  Speaker 1: all of those and well that's how we reviewed on
• 25:50
  Speaker 1: the pain Pod rather succinctly our pain management medication options. So, folks,
• 25:56
  Speaker 1: I really want to thank you if your time here
• 25:58
  Speaker 1: today listening in to this rapid rundown of a djuvenant
• 26:03
  Speaker 1: pain management medications. So yep, in the big picture, it's
• 26:09
  Speaker 1: hey pain, sad to see you go hate pain. Pod Nation.
• 26:13
  Speaker 1: Hope to see you back to enjoy much more beyond
• 26:17
  Speaker 1: this adjuveant pain medication episode of The Pain Pod, but
• 26:22
  Speaker 1: thank you pain Podnation, and I look forward to our
• 26:25
  Speaker 1: next episode.
• 26:27
  Speaker 2: If you'd like to join Mark on the Pain Pod,
• 26:30
  Speaker 2: send us an email to publish you're at Pharmacy podcast
• 26:33
  Speaker 2: dot com and make sure to share the show and
• 26:37
  Speaker 2: subscribe on your favorite podcast directory.
• 26:40
  Speaker 1: Thanks for listening.